SUBJECTIVE: The patient returns today. He is a patient of Dr. John Doe. His right shoulder is not improved with physiotherapy. He has an MRI, which shows a question of superior labral tear. Also has some tendinosis.
OBJECTIVE: At this point in time, on exam, he has full range of motion to both shoulders, 4/5 strength of the right shoulder secondary to pain, positive impingement, and tenderness over the biceps region. Positive Speed’s test. Positive Yergason’s test.
ASSESSMENT: Right shoulder superior labral tear.
PLAN: At this point in time, we would like to obtain an MR arthrogram. We will see the patient back after this study and make definitive treatment decisions for surgery.
Sample #2
SUBJECTIVE: The patient is a (XX)-year-old right-hand dominant male who was seen in consultation at the request of Dr. John Doe for ortho evaluation of bilateral forearm stiffness. The patient has had forearm and elbow trouble as long as he can remember. At age (XX), he had a surgery in his left elbow and another one done later. The patient’s main concerns are inability to fully supinate on either arm. He has actually no pain, but his supination restrictions are bothersome. He feels that his loss of supination has been present as long as he can remember. He is able to type on the keyboard by adjusting with his shoulders. He has no trouble with flexion and extension of his elbow. Prior surgeries are as mentioned. He reports no medicines on a regular basis. He had no allergies to medicines. He is divorced and has two children. The patient does not smoke and drinks on occasion. He enjoys reading, running, biking, skating, and working out at the gym.
OBJECTIVE: The patient is 5 feet 7 inches and weighs 158 pounds. On physical examination, he is a very pleasant, active, healthy-appearing male in no distress. He has a prominent bone along the right lateral elbow. This appears to move when he rotates his forearm and is consistent with radial head clinically. He has no evidence of varus or valgus deformity, and this deformity is fairly normal carrying angle symmetrically. His elbow flexion bilaterally is greater than 140 degrees, and he can fully extend both elbows. His pronation is proximally 60 to 70 degrees bilaterally. His supination, on his left, is limited between 10 and 20 degrees, and on his right, it is approximately 30 degrees. He has no tenderness at his wrist. There is no evidence of carpal instability or instability at the distal radioulnar joint. He has no tenderness into his forearm. No masses, warmth or erythema are noted. He has well-healed surgical incisions over the lateral left elbow and over the radial head proper. No prominence is noted in this region. We will obtain x-rays of both forearms today. This demonstrates the ulnotrochlear joint to be located and intact on both elbows with some mild hypertrophic changes noted at the coronoid. On the left elbow, the radial head has been resected, and on the right elbow, the radial head is posteriorly dislocated and overgrown. This represents the prominence seen clinically on the right elbow. Interosseous membrane and space is well preserved, and there is no evidence of synostosis. There is some mild ulnar positivity on both wrists with no evidence of carpal impaction as can be seen with these forearm films. We did not have dedicated elbow films nor do we have dedicated wrist films.
ASSESSMENT AND PLAN: Bilateral forearm supination contractures. Presumably, he has had congenital dislocations of both radial heads. On the left side, his first surgery was most likely a reduction of the radial head with attempted stabilization. The second procedure was most likely a radial head resection at that time. He felt that his surgery may have helped the prominence but did not improve his forearm rotation. We discussed that in order for the forearm to rotate that it involves motion, both at the proximal radioulnar joint, the interosseous membrane, and at the distal radioulnar joint. Our concern is that his contracture has been so long term that obtaining any further supination would be quite unpredictable surgically. This would also run the risk of destabilizing the forearm architecture such as the interosseous membrane and distal radioulnar joint, which may precipitate a further ulnar positivity in the setting of a previous radial head resection. Given this complicated case, we would like to consult upper extremity specialists for consideration. Again, currently, the patient has absolutely no pain.
Sample #3
SUBJECTIVE: The patient is a (XX)-year-old male who presents as a referral from Dr. John Doe for evaluation of right shoulder rotator cuff tear. His history was remarkable for right shoulder pain occurring about four months or so ago. However, his shoulder is increasingly improved in terms of his pain. It is zero today on the visual analog scale. He feels that he can certainly live with his shoulder feeling like this at this time. He did undergo an MRI scan. This was reviewed. See below. Medical history is significant for history of hypertension. Social history is significant for patient being a nonsmoker. Occasionally drinks alcohol.
OBJECTIVE: On exam, the patient is 5 feet 8 inches, about 200 pounds. On examination of the right shoulder, he has full active abduction. His passive glenohumeral abduction is 90 degrees, passive external rotation is 50 degrees, supraspinatus strength is 5/5, external rotation strength is 5/5, and internal rotation is to his lumbar spine. He has negative Hawkins, negative Neer test.
MRI scan of the right shoulder was reviewed. It shows a retracted full-thickness tear of the supraspinatus tendon. He also has a tear of the subscapularis deep fibers.
ASSESSMENT:
1. Right shoulder pain, which has significantly improved.
2. He has a full-thickness tear of the supraspinatus, which measures approximately 1 to 2 cm.
3. He has a partial tear of the subscapularis with a negative lift-off test.
PLAN: Outpatient physical therapy to work on strengthening of the right shoulder and rotator cuff. He has excellent function at this time and minimal pain, but we think physical therapy will encourage him to develop a home exercise program, which will help preserve his excellent function, and he will follow up with us in three months.
